Emergency Medical Services. Medical Director Handbook

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Emergency Medical Services

Medical Director Handbook

Prepared by:

Section of Community Health and EMS Division of Public Health

Department of Health and Social Services Box 110616

Juneau, AK 99811-0616

(907)465-3141 (907)465-4101 (fax) matt_anderson@health.state.ak.us

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Introduction and Overview

Physician Medical Directors serve as the cornerstone of Emergency Medical Services in Alaska. They provide guidance and supervision to over 4,000 Emergency Medical Technician-Is, EMT-IIs, EMT-IEMT-IIs, and Mobile Intensive Care Paramedics. They develop and adopt standing orders, ensure proper training, and evaluate the performance of individuals and agencies.

This handbook is designed to assist Physician Medical Directors in Alaska in fulfilling their responsibilities in an effective manner and in accordance with applicable statutes and regulations.

The Section of Community Health and EMS maintains and distributes a Medical Director’s Manual which provides more detailed information about the roles and responsibilities of a Physician Medical Director, including copies of regulations and sample standing orders, as well as copies of treatment guidelines. The manuals are free to Physician Medical Directors and can be requested from the Section at the address listed on the cover.

Although this handbook contains less detail, it addresses the operational responsibilities of a physician medical director contained in Alaska regulations. When a section is based on a regulatory requirement, the regulation citation can be found in the text or as a footnote. Since the statutes and regulations govern some of the activities of Physician Medical Directors, every attempt has been made to characterize them accurately. However, in the event that a conflict exists between this handbook and Alaska statutes or regulations, the latter will be considered to set the standard.

The Section of Community Health and EMS intends to revise this manual annually and hopes that individuals interested in improving medical direction will provide suggestions for improving it.

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The Structure of Medical Direction in Alaska

For the purposes of coordinating EMS activities in Alaska, the state has been divided into

regions.1 The State EMS Medical Director is responsible for “the development, implementation, and evaluation of standards and guidelines for the provision of medical direction within the state’s EMS system.”2

The responsibilities of the State EMS Medical Director, and the medical directors of certified EMS agencies and personnel, are prescribed in regulation. The table below provides contact information for state, federal, and regional EMS medical directors. A complete list of Physician Medical Directors can be found in the Alaska Emergency Medical Services Directory.

Medical Director Contacts

Coverage Contact Telephone FAX Electronic Mail

State Ken Zafren, M.D. 10181 Curvi Street Anchorage, AK 99516

(907) 346-2333 346-4445 _{zafren@alaska.com}

Federal (IHS) Frank Sacco, M.D.

Department of Surgery

Alaska Area Native Health Center P.O. Box 107741 Anchorage, AK 99510-7741 257-1284 257-1985 Interior Region Danny Robinette, M.D.

1919 Lathrop Street, Suite 100 Fairbanks, AK 99701

452-1761 452-8935

Mat-Su Borough

Roger Swingle, M.D.

Valley Hospital Emergency Department P.O. Box 1687 Palmer, AK 99645 745-4813 745-4850 North Slope Borough Donna Hephinger, M.D.

Samuel Simmonds Memorial Hospital P.O. Box 29 Barrow, AK 99723-0029 852-4611 852-9220 852-2826 Northwest Arctic Region Janette Shackles, M.D. Jean Snyder, M.D.

Maniilaq Medical Center P.O. Box 43 Kotzebue, AK 99752 442-3321 442-2728 Norton Sound David Head, M.D. P.O. Box 966 Nome, AK 99762 443-3311 443-3139 Southern Region Gilbert Dickie, M.D.

Alaska Regional Hospital Emergency Department 2841 DeBarr Road Anchorage, AK 99508 264-1222 (Work) 272-1426 (home) 264-2004 Southeast Aric B. Ludwig, M.D.

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Region 3260 Hospital Drive Juneau, AK 99801

Yukon-Kuskokwim

Yukon-Kuskokwim Health Corp. P.O. Box 528

Bethel, AK 99559

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Statutes and Regulations Related to Physician Medical Directors

Many of the responsibilities of physician medical directors can be found in the Alaska administrative code (regulations) which have been developed and promulgated based on the authority of certain statutes. Throughout this handbook, when the reader sees the initials “AAC,” the citation is a regulation. The prefix “AS” means the citation refers to a statute. The statutes enabling most regulations related to the training and certification of emergency medical personnel are AS 18.08.080, AS 18.08.082, and AS 18.08.084. To implement these statutes, the Department of Health and Social Services has developed regulations dealing with: Emergency Medical Technicians; Defibrillator Technicians, Emergency Medical Dispatchers; Emergency Medical Technician Instructors and Emergency Trauma Technician Instructors; ground and air medical services; Medical Directors, trauma centers; and the Alaska Trauma Registry. These regulations can be found in 7 AAC 26.010 - 7 AAC 26.999. In addition,

regulations concerning Do Not Resuscitate identification and protocols were recently enacted by the department. These regulations can be found in 7 AAC 16.010 - 7 AAC 16.090.

Mobile Intensive Care Paramedics are registered by the Department of Commerce and Economic Development, Division of Occupational Licensing, through the Alaska State Medical Board. The enabling statute for the MICP regulations (12 AAC 40.300 - 12 AAC 40.390) is AS 08.64.107.

Some immunity from liability is afforded physician medical directors of EMTs, Emergency Medical Dispatchers, certified ground and air medical services, and some others, by AS

18.08.086. Physician Medical Directors of MICPs receive some immunity from liability through AS 08.64.366.

Two recent statutes directly affect Emergency Medical Services Personnel. In 1995, AS 09.68.120 was amended to allow mobile intensive care paramedics, emergency medical

technicians, and physician assistants to pronounce death in accordance with standards set forth in AS 18.08.089 and when:

Pronouncing Death in the Field

1. the paramedic or emergency medical technician is an active member of an emergency medical service certified under AS 18.08;

2. neither a physician licensed under AS 08.64 nor a physician exempt from licensure under AS 08.64 is immediately available for consultation by radio or telephone communications; 3. the paramedic, physician assistant, or emergency medical technician has determined, based

on acceptable medical standards, that the person has sustained irreversible cessation of circulatory and respiratory functions.

The clinical criteria for pronouncing death are contained in AS 18.08.089 and are available upon request from the section. Physicians are encouraged to specify, in standing orders, how the EMTs and MICPs under their medical direction can best comply with these laws.

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Do Not Resuscitate Identification and Protocols - The Alaska Comfort One Program

On October 10, 1996, regulations went into effect which establish a statewide Do Not

Resuscitate protocol for physicians, EMS responders, and other health care providers. They also adopt, by reference, the Montana Comfort One© standards for do not resuscitate identification, including forms, cards, necklaces, and bracelets.

These regulations provide many tangible benefits to DNR patients and health care personnel. Most importantly, they include a standard system for identifying DNR patients and provide specific guidance on what treatments should be rendered and which should be withheld. Patients who do not have valid DNR orders should be treated in accordance with normal

operational guidelines and protocols, including the appropriate use of the authority to pronounce death in the field, conferred by AS 08.64.089.

Several communities have well developed and functional systems for responding to DNR

patients, for example, the “Expected Home Death Program” used in Anchorage. Although these regulations supersede local programs for identifying Do Not Resuscitate patients and specify the circumstances under which CPR may be withheld or terminated, they may be augmented by local programs. Local programs may address issues such as palliative care, EMS system access, death scene investigation, etc.

Existing DNR programs should review their standards and protocols to ensure compliance with the new regulations. Specifically, local systems must honor the Comfort One© identification system and must treat Comfort One© patients in accordance with the Alaska DNR protocols. Since these regulations are silent on the palliative care which can be given to minimize the patient’s pain and discomfort, EMS physician medical directors are encouraged to provide guidelines regarding this subject for the EMS personnel under their directorship.

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EMT Levels in Alaska

Although the EMT/EMT-Instructor certification regulations mandate a core curriculum, in some cases, the emergency medical service's physician medical director has added procedures and/or medications to the EMT's arsenal of treatment methods. The ability of the physician medical director to tailor emergency care practices to the community's needs (and the EMT's capabilities) results in a higher level of care than would be possible otherwise. In many parts in Alaska, emergency medical responders are trained to the EMT-II level or above.

The scopes of authorized activities are found in the following regulations:

Emergency Trauma Technicians 7 AAC 26.440

EMT-I, EMT-II, EMT-III 7 AAC 26.040

Mobile Intensive Care Paramedics 12 AAC 40.370

EMTs may be authorized to perform additional procedures or use additional medications by the Physician Medical Director in accordance with 7 AAC 26.670. This is covered in detail on page 21.

Emergency Trauma Technician (ETT)

An ETT is trained in a 44 hour program to provide basic life support, including splinting, bandaging, bleeding control, and the use of free flow oxygen. This level of training is prevalent in most small communities and industrial settings in Alaska. Emergency Trauma Technicians are often categorized as “first responders” because of their roles and training.

Emergency Medical Technician-I (EMT-I)

The Emergency Medical Technician-I is equivalent to the National Standard EMT-Basic, as described in the United States Department of Transportation (USDOT) national standard

curriculum. The EMT provides basic life support such as splinting, hemorrhage control, oxygen therapy, suction, and CPR. Properly trained EMTs may use automated external defibrillators.

Defibrillator Technician (ETT-D, EMT-D)

Defibrillator technicians are typically Emergency Medical Technicians or Emergency Trauma Technicians who are trained to use defibrillators. Some defibrillator technicians are authorized to use manual defibrillators. Most are trained and authorized to use automated external

defibrillators.

Emergency Medical Technician-II (EMT-II)

The Emergency Medical Technician II level exceeds the National Standard Training Program EMT-Intermediate, developed by the USDOT. The EMT-II class prepares the student to initiate intravenous lines and administer fluids and certain medications, such as 50% dextrose.

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Emergency Medical Technician-III (EMT-III)

The EMT-III program is designed to add some advanced cardiac care skills to those the EMT has learned already. Also included in the training program is the use of morphine, lidocaine,

atropine, and epinephrine.

Mobile Intensive Care Paramedic (MICP)

Mobile Intensive Care Paramedics are licensed by the Alaska Department of Commerce and Economic Development through the Alaska State Medical Board. MICP's provide care in excess of the EMT-III level and function under the direct or indirect supervision (standing orders, etc.) of a physician. Generally, paramedics are found in the most populous areas of Alaska, including Anchorage, Fairbanks, Kenai, Soldotna, Nikiski, Juneau and Ketchikan. In some of these

communities, all pre-hospital emergency medical care is provided by Mobile Intensive Care Paramedics. In others, the MICP may act as a supervisor or EMS director.

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Physician Medical Director Qualifications and Training

7 AAC 26.630 requires that physicians be authorized to practice medicine in Alaska in order to serve as physician medical directors for state certified ground or air medical services or

individuals. This authorization may be conferred by license as a physician in Alaska or be based on working under the auspices of the federal government.

Department Approved Orientation

A physician medical director must participate in a “department approved orientation” within one year after accepting the responsibilities of a medical director. In an effort to make the

orientation as available as possible, the Section of Community Health and EMS has developed a videotape and manual which provides specific information on medical direction in Alaska. However, as the complexities of prehospital emergency care continue to increase, so does the need for additional training of physician medical directors. To that end, the State EMS Medical Director coordinates the development of a “Physician’s Track” at the State EMS Symposium each year. This one day session often includes information relevant to the needs of the physician medical director. In addition, the symposium serves as an opportunity for the annual “Medical Director’s Meeting,” which is facilitated by the State EMS Medical Director. Typically, the meeting is held on Saturday morning during the weekend of the State EMS Symposium.

Specific Requirements for Ground Medical Services

To be a medical director for a state-certified EMT-III, ETT-D, or EMT-D, a physician must be trained by the American Heart Association in advanced cardiac life support.

Specific Requirements for Air Medical Services

• To be a medical director for a state certified medevac service, a physician must have 16 hours of department-approved medevac training.

• To be a medical director for a state-certified critical care air ambulance service, a physician must have 16 hours of department-approved aeromedical training and be either board certified or board eligible in, or have other department-approved credentials demonstrating competence in, critical care or aeromedicine.

• To be a medical director for a state-certified specialty aeromedical transport team, a physician must have 16 hours of department-approved aeromedical training and be board certified or board eligible in the medical specialty for which the aeromedical team is to be certified.

• The medical director of a service based outside Alaska must be licensed in the state in which the service is based.

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Quality Assurance and the Physician Medical Director

The activities of Physician Medical Directors are critical to the improving and assuring the quality of patient care in a community. The regulations related to the responsibilities of medical directors,3 set forth the minimum responsibilities of a medical director. Many services,

particularly those with a larger than average number of EMS providers and those which have an extensive scope of activities, will need the physician medical director to have more involvement than required by the regulations. The needs, capabilities, and expectations should be understood by the medical director and the emergency medical service. In general, there are three areas in which the physician medical director can be of enormous benefit to the EMS agency.

Approving Standing Orders

The standing orders provide clear guidance to the EMS personnel about what activities should be performed on scene, by whom, and under what circumstances. They should be written in a manner which allows them to be used for reference, in training, and in evaluation of

performance. It is important to note that, although EMT-I, EMT-II, and EMT-III training programs must cover certain topics and skills, e.g. the use of advanced airway devices, it is the physician medical director who may expand, or contract, the scope of activities of the EMS provider based on local needs and constraints. Additional skills and medications should be taught in conformance with 7 AAC 26.670.

Approving Continuing Medical Education

The physician medical director is responsible for approving a plan of continuing medical

education for each state certified EMT supervised. In practice, the Medical Director works with the EMS agency’s representatives to ensure coverage of essential material. However, if the Medical Director identifies areas of weakness or concern, it is within his or her rights to require the EMTs supervised to obtain continuing education in the necessary area(s).

Reviewing EMS Runs

A review of each EMS response should be performed by the physician, or designee, to ensure compliance with standing orders, to verify that the documentation was adequate, and to feed this information back into the training process. In small services, the physician medical director typically reviews all responses. In large services, it is common for the physician medical director to have system in which all runs are reviewed by a particular person, such as the service’s EMS coordinator or Rescue Captain. The Physician Medical Director establishes criteria which identify the reports which are forwarded to him or her for review.

Most EMTs find it enormously helpful to be able to sit down with the Medical Director to

review particular runs in a relaxed and educational atmosphere. Although the regulations require quarterly reviews, busy services will need reviews performed more frequently. Run reviews may be applied towards the continuing medical education requirements for recertification.

3 _{7 AAC 26.610 - 7 AAC 26.700}

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What Am I Signing Again?

Physician Medical Directors are often asked to sign documents related to EMS training and certification. It’s always important to read the “fine print” before signing something. The following are descriptions of the forms, and a summary of what the physician’s signature means.

Applications for State Licensing, Certification and Recertification

Applications for certification of an EMT-II or EMT-III, and for licensing of a Mobile Intensive Care Paramedic, are the forms most frequently given to physician medical directors for signing. The physician’s signature means that he or she supports the credentialling of the individual at the level indicated on the application and that the physician will fulfill the responsibilities of a medical director outlined in applicable regulations.

Applications for Emergency Medical Service Certification

Agencies applying for certification as a ground or air medical service must have a Physician Medical Director. The signature of the Physician Medical Director verifies that he or she will fulfill the responsibilities outlined in the regulations, such as approval of treatment protocols and review of patient care provided by each of the emergency medical providers within the agency.

Applications for registration with the National Registry of EMTs

The National Registry of Emergency Medical Technicians is a non-profit agency located in Columbus, Ohio, which has developed a highly regarded process for testing and credentialling Emergency Medical Technicians at the Basic, Intermediate, and Paramedic levels. Registration through the National Registry of EMTs does not confer legal authorization to provide advanced life support. The individual must be credentialled in Alaska at the appropriate level in order to provide ALS.

The applications for initial registration and reregistration require the support of a physician medical director. The physician’s signature confirms that the individual has completed the necessary requirements for registration and that the physician supports the registration of the individual by the National Registry of EMTs.

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Standing Orders

By regulation, EMS medical directors are required to approve treatment protocols or medical standing orders that delineate the medical procedures that may be performed by the certified or licensed medical care personnel on the service4.

Contents and Development of Standing Orders: Standing orders should clearly and

unequivocally delineate the advanced life support procedures which may be carried out by each level of provider on the service and under what circumstances. For medical events in which a presumptive diagnosis is not necessary (e.g. chest pain), an assessment based format may be more useful. In cases where more detail must be known before treatment, as may be necessary to treat a patient with a tension pneumothorax or who is in ventricular tachycardia, a diagnostic based format may be necessary.

The names of the individuals able to perform care under the standing orders and the person responsible for the medical aspects of patient care, should be clear from the standing orders. The standing orders should include a written policy for how certified personnel are to deal with an intervener physician, or the patient's private physician, who wishes to assume responsibility for patient care at the scene or en route to the hospital.

Additionally, it should be clear who is, and who is not, covered by the standing orders and under what circumstances. Some EMTs may believe that their service’s standing orders cover them when they are outside their service area or off duty. Geographical and other constraints should be clearly covered.

It is advisable to have a list of persons who are covered by the standing orders. In some cases, an individual might be prohibited from providing advanced life support for administrative reasons. For example, the service may have a policy that EMT-IIIs must attend six meetings with the medical director or their ability to provide ALS will be suspended. The service and medical director should make such policies, and their consequences, clear to all EMS providers on the service.

Standing orders should be reviewed periodically. The Section of Community Health and EMS recommends that they be reviewed at least annually, and more frequently after being revised or rewritten.

Sample standing orders can be obtained from the Section of Community Health and EMS or from the nearest Regional EMS Office.

4 _{7 AAC 26.640, 7 AAC 26.650}

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Responsibilities of Physician Medical Directors

This section provides information on the basic responsibilities of physician medical directors. These responsibilities can be found in state regulations 7 AAC 26.610 - 7 AAC 26.700. It may seem at first that the requirements are voluminous. However, most of them overlap, so the overall impact is minimized. For example, the requirement for the medical director to approve standing orders is included in both the section related to certified persons and the section related to certified organizations.

Mobile Intensive Care Paramedics (MICPs)

Regulation Citation: 12 AAC 40.315

Although an MICP must be under the sponsorship of a physician medical director at all times, the actual responsibilities to the individual MICP are not specified in regulation. Physician Medical Directors for MICPs are encouraged to use the following section concerning certified persons as an example of the responsibilities which should be undertaken. The responsibilities of Physician Medical Directors of certified agencies which employ MICPs are covered in the section related to certified organizations.

Certified Persons

This section of the regulations relates specifically to the medical directors of Emergency Medical Technicians I, II and III, and Defibrillator Technicians.

Emergency Medical Technicians

An EMT-II or EMT-III without a physician medical director may not legally perform advanced life support until the individual has obtained a medical director in accordance with applicable regulations. The license of an MICP is considered to be suspended when the individual MICP does not have a physician sponsor approved by the board.

The physician agrees to:

• provide direct or indirect supervision of the medical care provided by each state certified EMT-I, EMT-II, or EMT III.

• establish and annually review treatment protocols.

• approve medical standing orders that delineate the advanced life-support techniques that may be performed by each state certified person and the circumstances under which the

techniques may be performed.

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• approve a program of continuing medical education for each state certified person supervised.

The department may grant a written waiver of the requirement for the quarterly on-site supervisory visits based on difficult geographic, transportation, or climatic factors. The physician medical director must request the waiver in writing. The request must include information on the methods which will be used by the Physician Medical Director to provide appropriate supervision.

Defibrillator Technicians

In addition to the responsibilities outlined under “Emergency Medical Technicians,” the

physician must review each run on which a shock was delivered to the patient and must arrange for quarterly training sessions which provide an opportunity for the Defibrillator Technician to demonstrate the ability to perform the skills in compliance with local protocols. The regulations require the physician to “provide or arrange for” the sessions, not necessarily teach each one.

Emergency Medical Dispatchers and EMD Centers

Regulations regarding the certification of Emergency Medical Dispatchers became effective on April 7, 1996. The regulations require that dispatchers routinely providing prearrival emergency medical instructions to callers be certified by the department. One of the requirements for certification is that the emergency medical dispatch center be supervised by a physician. Evidence of this supervision is found on the EMD’s application for certification.

The Physician Medical Director of a EMD center must:

• approve an emergency medical dispatch priority reference system; the system must include caller interrogation questions, pre-arrival EMS instructions, and protocols matching the dispatcher's evaluation of severity of injury or illness and the number of victims with vehicle response modes and configurations;

• provide indirect supervision of medical triage decisions and treatment instructions provided by EMD's;

• periodically review on at least a monthly basis a sample of medical triage decisions and treatment instructions provided by EMD's to callers.

The medical director of the emergency medical dispatcher services may be the medical director of an ambulance service dispatched by the same agency or business.

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Certified Organizations

“Certified organizations” include ground and air medical services which provide advanced life support or basic life support. Ground medical services which provide only basic life support are not required to be certified, although there are some benefits to those services that are (and their medical directors). Services providing advanced life support are required to be certified.5 The medical director of a state certified emergency medical service must:

• approve treatment protocols or medical standing orders that delineate the medical procedures that may be performed by the certified or licensed medical care personnel;

• review, at least quarterly, the patient care provided by each certified or licensed medical person;

• for ground medical services, establish transportation/transfer arrangements in cooperation with emergency department physicians at the nearest appropriate referral hospitals: these arrangements shall specify the primary destination of all categories of emergency patients including burns, central nervous system injuries, pediatric emergencies, high risk infants, behavioral emergencies, and cardiac emergencies; and

• for ground medical services, establish a written policy for how certified personnel are to deal with an intervener physician or the patient's private physician who wishes to assume

responsibility for patient care at the scene or en route to the hospital.

In addition to the requirements outlined above, the medical director for a state-certified medevac service, critical care air ambulance service, or specialty aeromedical transport team must agree to advise on the medical requirements of patient transportation in the airborne environment.

The department may grant a written waiver of the requirement for the quarterly on-site supervisory visits based on difficult geographic, transportation, or climatic factors. The physician medical director must request the waiver in writing. The request must include information on the methods which will be used by the Physician Medical Director to provide appropriate supervision.

Training Programs

All EMS training programs benefit from the involvement of Physician Medical Directors. EMT-II and EMT-EMT-III initial training programs are required to have a physician medical director. In most cases, the medical director of an EMT-II or EMT-III training program also will be the medical director for those who successfully complete the program. However, it is important to note that physicians are not “required” to sponsor an individual. A Physician Medical Director

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should only agree to sponsor those persons who meet the qualifications for certification and have demonstrated the medical skills and maturity commensurate with the level of responsibility. The physician medical director of an EMT-II or EMT-III training program must:

• be available in person or by telephone to answer specific questions arising during the training course.

• ensure that additional medications or procedures are taught and evaluated in compliance with current medical practice and guidelines.

• assume responsibility for the techniques and procedures performed as part of the course, such as venipunctures, fluid infusion, and injection.

There are standard EMT-II and EMT-III curricula developed and maintained by the Section of Community Health and EMS which serve as the basis for training and testing for these levels. The medical director may delegate to another physician or physicians the responsibility for conducting some of the training described in this section.

The medical director assumes responsibility for the technical procedures performed as part of the course, but has no obligation to provide sponsorship to any student outside of the classroom setting or after the course is completed. It is important for the Physician Medical Director to make the extent and duration of his or her sponsorship clear to students. For example, a

Physician Medical Director may support an individual becoming trained to the EMT-II, level but may wish to see how the person does in class before agreeing to assume the responsibilities of a physician medical director for the individual.

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Frequent Activities of Physician Medical Directors

The following sections of the handbook are intended to provide assistance to Physician Medical Directors in performance of activities related to the sponsorship of agencies and individuals.

Authority

The Physician Medical Director for an EMS agency or prehospital emergency medical responder, acting in accordance with applicable statutes and regulations, has the authority to require certified individuals to meet continuing medical education requirements and to demonstrate the ability to perform care in accordance with the service’s standing orders.

Further, the Physician Medical Director may suspend or withdraw directorship of any individual who cannot perform to the medical director’s standards. In circumstances where a contractual agreement exists between an agency and a Physician Medical Director, it is imperative that issues regarding authority be clarified and understood by all parties, including the emergency medical personnel supervised by the physician.

Adding an Individual to a Service’s Roster

To add an individual to a service’s roster, two events should occur. First, the Physician Medical Director of the agency must agree to serve as the Physician Medical Director of the individual. This is evidenced by a signed application form or letter. Second, the Section of Community Health and EMS should be notified by the physician medical director, or representative of the certified agency, that the individual EMT or MICP is a member and will be providing care. Both these events can be combined in one letter (see page 24).

Delegation of Certain Responsibilities

In most circumstances, the physician medical director is responsible for reviewing the emergency medical responses performed by the individuals and agencies under his or her supervision. However, some geographically isolated services may have a need to perform run reviews at a local level. If approved by the department, a medical director may delegate review of EMS reports and patient care forms to another physician, mobile intensive care paramedic, registered nurse, mid-level practitioner, or EMT with supervisory experience. The person acting as delegate shall send to the medical director copies of the EMS reports or patient care forms.

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Applications from Military Medical Personnel

Alaska’s EMS Regulations allow “military medical training” to be applied towards the experience requirement for EMT-II and EMT-III training. The equivalence of the experience must be approved by the Section of Community Health and EMS OR the Regional EMS Office for the area in which the course is being taught.

The military medical experience must meet or exceed the scope of certified activities for the level of training for which the equivalence is being requested and must include significant prehospital experience.

Requests for determination of equivalence of military medical training must be received in a timely manner to ensure that they are approved or denied prior to the first day of the course. Potential EMT-II students asking CHEMS or the Regional EMS Office to determine whether their six months of military medical experience are the equivalent of six months experience as an EMT-I or EMT-II should make the request in writing and provide documentation supporting their request. The documentation should include the dates of service, the roles and

responsibilities as a military medical provider, and a summary of experience as a pre-hospital emergency care provider. A letter from the applicant’s medical director supporting the request and stating that the applicant’s experience is the equivalent of that of an EMT-I or EMT-II is strongly encouraged.

Individuals who do not meet the requirements outlined in these regulations and who have not had a determination of the equivalence of military medical training prior to the first day of the course will be denied certification based on noncompliance with the regulations.

It is the responsibility of the EMT-II or EMT-III course instructor to ensure all students are eligible to enroll in the course. This is best accomplished by requiring each student to show his or her valid EMT-I or EMT-II certificate from the Alaska Department of Health and Social Services. A valid card from the National Registry of Emergency Medical Technicians is not sufficient evidence.

Instructors who allow ineligible students into EMT-II or EMT-III training programs may risk administrative action in accordance with 7 AAC 25.140.

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Adding Additional Medications or Procedures

Basically, there are three categories of medications and procedures:

• those contained in the normal scope of certified activities (7 AAC 26.040);

• those emergency care procedures or medications which are not in the scope of certified activities but are consistent with the scope of training and mission of the EMT-I, EMT-II or EMT-III (e.g., needle chest decompression) ; and

• those procedures or medications which are outside the scope of training or mission of an emergency medical technician (e.g., administration of antibiotics, suturing).

In accordance with 7 AAC 26.670, a Physician Medical Director may authorize an individual to use additional medications and procedures, consistent with the second category above.

Procedures or medications in the third category are not addressed by this regulatory authority. Therefore, the immunity from liability protection of AS 18.08.086 would not apply. The State EMS Medical Director is responsible for assisting the Section of Community Health and EMS in categorizing medications and procedures.

Approval of additional medications and procedures is a two step process. The first step is submitting a request which is accompanied by a plan for training and evaluation of the skills or medications.

The second step consists of providing the training and sending the Section of Community Health and EMS a list of the individuals who are authorized to use the additional medications or

procedures.

Withdrawing Directorship

When a physician chooses to withdraw as a Physician Medical Director, he or she must notify the Section of Community Health and EMS and each person and agency sponsored by the physician.

The agency for which the person serves as a Physician Medical Director will have its certificate suspended until another physician assumes the responsibilities of a Physician Medical Director. Individuals formerly supervised by the physician will not be authorized to provide advanced life support until another physician assumes the responsibilities of medical director.

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Recommending Administrative Actions

Regulation Citation: 7 AAC 26.140 (b) allows the Department of Health and Social Services to suspend, revoke, or refuse to issue a certificate based on specific documentation from the Physician Medical Director and his or her recommendation that the individual be decertified.

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Sample letters

The following sample letters provide the types of information needed by the Section of

Community Health and EMS. You are not required to use these letters. However, letters sent to the EMS office regarding the certification of an individual or agency should include the name, level, and certification status of the individual or agency, as well as a description of the action which is being requested.

If the Physician Medical Director prefers to sign one letter confirming sponsorship of individuals, rather than signing each application, it is perfectly acceptable.

It may be more efficient for an agency to submit one letter in which one physician resigns as the agency’s medical director and another accepts the responsibilities. This, too, is acceptable, so long as the information is clear and complete.

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Confirmation of Directorship

[Date of Letter]

[Physician’s Name & Mailing Address] Section of Community Health and EMS Department of Health and Social Services Box 110616

Juneau, AK 99811-0616 To whom it may concern:

This letter confirms that I will serve as the physician medical director for the following individuals:

Roy DeSoto EMT-II 90834353

Johnny Gage EMT-III 93343235

Joe Smith EMT-II 99823434

I will fulfill the responsibilities of a physician medical director outlined in 7 AAC 26.610 - 7 AAC 26.700 and will notify your office of any changes in sponsorship.

The contact within the [name of agency for which you serve as Physician Medical Director] is [name of contact]. [He/She] can be reached at [telephone].

Please contact me at [telephone] if you have any questions. Sincerely, [Name] cc: Regional EMS Office

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Withdrawal of Directorship

[Date of Letter]

The following individuals have left the [name of agency] and are no longer under my supervision:

A copy of this letter will be sent to each of the individuals listed. Please update your records accordingly.

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Transfer of Directorship

[Date of Letter]

I am resigning from my position as physician medical director of [name of agency] and will no longer be serving as the physician medical director for the following individuals:

The new physician medical director for this service will be [name of new medical director]. [She/he] will send you a letter confirming acceptance of the responsibilities of a Physician Medical Director.

A copy of this letter will be sent to each of the individuals listed. Please update your records accordingly.

(27)

Request for Training: Additional Medications or Procedures

[Date of Letter]

Based on current medical practices, and my review of the emergency medical responses of the [name of EMS agency], I wish to authorize certain individuals within the agency to [name or description of additional skill or medication].

Attached is the plan for training and evaluation of the additional skills.

Please provide written confirmation that this proposal has been accepted. You may contact me at [telephone] if you have any questions.

Sincerely, [Name] attachments: Plan for training and evaluation

cc: State EMS Medical Director

(28)

Confirmation of Training: Additional Medications or Procedures

[Date of Letter]

This letter confirms that I have provided training and evaluation of additional skills and

medications in accordance with 7 AAC 26.670 and am authorizing the following individuals to [name or description of skill or medication.]

Please place a copy of this letter in each individual’s file.

Please contact me at [telephone] if you have any questions. Sincerely, [Name] attachments: Plan for training and evaluation

(29)

Delegation of Responsibilities

[Date of Letter]

Because of the great distance between my office and the [name of EMS agency], I am delegating the immediate review of EMS runs to [name of delegate]. I have informed [him/her] of my expectations regarding the reviews and will be receiving copies of the run sheets on a periodic and timely basis.

(30)

Sample Letter for Military Medical Experience Equivalence

Letter can be sent to either Section of Community Health and EMS or the Regional EMS Office responsible for the area in which the course is being held.

Emergency Medical Services Unit Section of Community Health and EMS Division of Public Health

Department of Health and Social Services P.O. Box 110616

Juneau, AK 99811-0616 To Whom It May Concern:

Attached is documentation of military medical experience, including dates and scope of care provided, for the following individuals: [one or several names]. I have reviewed the

documentation and believe it provides evidence that the individual[(s)] have the equivalent of six months of experience as an:

Emergency Medical Technician-I Emergency Medical Technician-II

Please contact me if you have any questions or if you need additional documentation. Sincerely,

_________________

Physician Medical Director

(31)

Index

A

Address, 23, 24, 25, 26, 27, 28 Air Medical Service, 11 Ambulance Service, 7 Applications, 13 C CPR, 8, 9 D Defibrillator Technician, 7, 9, 15, 16 Dispatchers, 7, 16 E

Emergency Medical Dispatcher, 7, 16

EMT-I, 2, 9, 10, 11, 12, 13, 15, 17, 18, 20, 23, 24, 25, 27 EMT-II, 2, 9, 10, 11, 12, 13, 15, 17, 18, 20, 23, 24, 25, 27 EMT-III, 2, 9, 10, 11, 12, 13, 15, 17, 18, 20, 23, 24, 25, 27

ETT, 9, 11

G

Ground Medical Service, 11

I Instructor, 9 M Medical Board, 7, 10 Medical Director, 1, 2, 5, 7, 9, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 N Name, 23, 24, 25, 26, 27, 28 National Registry, 13 P Paramedic, 10, 13 Physician, 2, 5, 7, 9, 11, 13, 15, 19, 21, 23, 24, 25, 26, 27, 28 Protocols, 8 R Recertification, 13 Region, 5, 6 Regulations, 7, 16 Roster, 19 S Standing Orders, 12, 14

State EMS Medical Director, 5, 11, 20, 26 Statutes, 7 Symposium, 11 T Trauma, 7, 9 U USDOT, 9

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Emergency Medical Services. Medical Director Handbook